Birthing at home: It takes a village

Elizabeth Payne, The Ottawa Citizen11.28.2010

Inukjuak resident Lindsey Mina gives birth to a boy - 11 pounds! - with support from her mother, Nancy Mina. such intimate scenes are rare in the North, where Inuit women from remote communites have been flown far from home to give birth at hopitals in larger cities.

SALLUIT, Que. — The Northern Lights shimmer, then fade. While most of the village sleeps, there is a celebration on the hill above town. In a building known simply as the Maternity, which overlooks this Inuit village in a fiord on the northern tip of Quebec, more than a dozen family and friends are waiting on Salluit’s newest resident.

When the baby is born — a girl — there are grins and handshakes. A midwife switches on white Christmas lights to signal the news to the village. In the morning, the tired young mother will pack her newborn into the hood of her amauti, the iconic parka in which Inuit carry their babies, and return home, where most everyone will have already heard of the arrival.

To say birth is a community event in Inuit villages like Salluit is an understatement.

Tiny footprints tell the story. Ink impressions on coloured paper decorate the walls of the birth centre. Each one represents a birth in this village of about 1,200 people since 2004, when the community became the third along Quebec’s Hudson Bay coast to bring birth home. For years, virtually all pregnant women were flown to southern hospitals where they waited alone for weeks and then gave birth among strangers; every footprint marks a step away from that widely disliked policy. Each stands for hope and a future in which there is greater autonomy over health.

The villages along the Hudson Bay coast in Nunavik are tightly knit, fly-in communities whose roads hum with all-terrain vehicles in the summer — some carrying entire families — and gaggles of children. The mostly Inuit population is young. The fertility rate among Canada’s Inuit is twice the national average. Hunting and fishing still provide “country food” — caribou, char and beluga — which, along with fresh-picked berries, are a much-loved part of most residents’ diets. The Inuit-run, Co-op grocery store, where red peppers sell for almost $5 each, provides the rest.

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Nunavik, which covers the northern third of Quebec, is negotiating to become a self-governing region within the province.

Residents are proud of their culture and fiercely attached to the land, which is stark and breathtaking. But there are serious challenges. This is also a world in which alcoholism, substance abuse, smoking and overcrowding are facts of life, where one quarter of babies are born to teenagers — even some 12-year-olds — where infant mortality rates are higher and life expectancy lower than the rest of the country. In mainly Inuit Nunavik, the life expectancy is about 66.7 years, compared with 79.3 in the rest of Quebec. Between 2000 and 2002, about 22 per cent of all deaths in Nunavik were the result of suicide; more than 10 times the provincial rate.

Against that backdrop, the successful battle by local communities to bring birth home may seem counterintuitive. But the Nunavik birth centres argue that more expensive health care does not mean better health for remote aboriginal communities. In fact, there is evidence that giving birth close to home, which costs less than flying women to far-off hospitals, results in better maternal and infant health, and improves the well-being of communities.

At a time when the federal government has made it a priority to improve maternal health around the world, some are asking why it’s not playing a greater role in improving dismal conditions in Canada’s North.

The revolution in birth in Salluit and other northern Quebec communities, and the creation of an innovative program that trains Inuit midwives, are viewed by many as models for other parts of Canada and the world. But, nearly 25 years after Nunavik’s first midwifery clinic opened in the village of Puvirnituq, obstetric evacuation remains a way of life for many women in Canada’s remote North.

The government of Nunavut adopted a maternal and newborn health-care strategy last year that calls for the establishment of regional midwifery services to bring more low-risk births back home to the territory. But Health Minister Tagak Curley acknowledged in an interview that without support from the federal government, progress will be slow.

“Prime Minister Harper must look in his own backyard before he starts being a Good Samaritan for other countries. We have some of the same problems as Third World countries with respect to health.” The Northwest Territories faces similar problems when it comes to reducing the number of women who are flown away from home to give birth.

Residents of villages like Salluit know they are lucky. “To bring birth back to the communities is to bring back life,” explains one elder from Puvirnituq.

In southern Canada, where nearly 30 per cent of babies are now delivered by caesarean section and most people live within two hours of a hospital, few know the story of Nunavik’s success. But the world is watching.

Researchers from Canada and around the globe have extensively studied Nunavik’s maternities, the three birth centres that serve women on Quebec’s Hudson Bay coast. A fourth centre opened in Kuujjuaq, on the eastern Ungava coast of Nunavik, in 2009. The World Health Organization celebrated the innovation in a letter to the Quebec government. “If there ever was an example of health promotion,” it wrote, “this is it.” The Society of Obstetricians and Gynecologists of Canada, the Royal Commission on Aboriginal Peoples, the World Bank and others have recognized the program as a model for meeting Millennium Development Goals for Safe Motherhood.

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In the years since 1986 when the first Nunavik birth centre opened in Puvirnituq, the maternities have been followed closely. A 2007 study of birth outcomes there found perinatal mortality rates were 0.9 per cent, or nine out of every 1,000 births, similar to the rates in Canada as a whole and lower than among similar populations in Nunavut and the Northwest Territories. Intervention rates were also low, with fewer than two per cent of women requiring C-sections. Overall numbers are relatively small, which makes comparisons less reliable, observes lead author Vicki Van Wagner, who teaches midwifery at Ryerson University in Toronto and has worked in Nunavik. But, her study concluded, the establishment of the birth centres in Nunavik has demonstrated that birth in communities is safe, and healthier for mothers and babies than the policy of evacuation.

“The establishment of birth centres has been fundamental for community healing,” she writes “and marks a turning point for many families who suffered from family violence in Nunavik.”

Not all research has been as glowing. A 2009 study in the Journal of Epidemiology and Community Health compared Nunavik’s midwife-centred approach to women in east Nunavik who gave birth with the help of doctors were flown south. The study determined there were slightly more perinatal deaths among births assisted by midwives than those in which physicians were the primary birthing attendants. The authors concluded, however, that the differences were not statistically significant. They also noted that many of the health disparities between Inuit and non-Inuit communities have to do with broader issues. With that in mind, the authors said the birth centres model may “bring vitality and other social and community benefits.”

Evidence from Greenland supports that. Infant mortality rates among Inuit there are much lower than among Canadian Inuit. Greenland has tackled chronic health problems, including smoking, alcoholism and crowded housing. It also allows most women to give birth in or near their own communities.

To many people, the benefits of giving birth at home are obvious.

“I can understand that some of you may think that birth in remote areas is dangerous,” said Salluit elder Jusapie. “We have made it clear what it means for our women to birth in our communities. And you must know that a life without meaning is much more dangerous.”

The success of the Nunavik clinics has challenged health officials to expand the way they assess health risks for indigenous communities.

Janet Smylie, a research scientist in aboriginal health at St. Michael’s Hospital in Toronto, says culturally appropriate health care “may challenge the world view of medically trained health professionals who are concerned with access to medical technologies.” Smylie was principal author of a report for the Society of Obstetricians and Gynecologists of Canada (SOGC) that recommended, among other things, “the need to provide health services for aboriginal peoples as close to home as possible.”

In 2007, the SOGC tabled a report that said aboriginal women should not have to choose between culture and safety. In it, author Carol Couchie, citing the success of Nunavik’s program, recommended that doctors, nurses and others work with indigenous communities to reform existing maternity programs.

The women of Nunavik’s Hudson Bay coast communities overwhelmingly agreed. They set the stage to create a health system that combines Inuit traditions with modern medicine.

“I doubt the world understood what a marked revolution it represented,” wrote Ottawa midwife Betty-Anne Daviss, who has worked in and written about the Nunavik maternities. “Here was a community, eight hours by plane from any hospital large enough to have caesarean section facilities or a neonatal intensive care unit, making a political decision to reject clinical logic to save the integrity of their cultural, personal and intuitive logic. In clear words and actions, Puvirnituq was willing to state that the risk of losing a baby was worth the benefit of returning birth to the Inuit community.”

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Until about the middle of the last century in Canada, Inuit babies were born in shelters, igloos or tents. Traditional midwives were sometimes available. When they weren’t, grandmothers, sisters, aunts, fathers or extended family members helped deliver babies.

After the Second World War, Inuit began to settle in communities with government services, including nurse-midwives and nursing stations, where growing numbers of babies were born.

But by the late 1960s and early 1970s, fewer trained midwives were working in nursing stations. Most small communities didn’t have doctors or midwives. Medical officers were alarmed by infant mortality rates. As air transportation became more accessible, the practice of flying women to large southern hospitals began in earnest.

Mortality rates gradually improved, though some research suggests this had more to do with improvements in living conditions. At least one study found evacuation caused more birth complications. In high-risk cases, lives were saved. But the policy of flying every pregnant woman south, even healthy, low-risk women, was taking a toll.

Women began to refuse to go. Some hid their pregnancies in loose clothing, knocking on nurses’ doors when they went into labour.

In 1982, Aani Tulugak, a resident of Puvirnituq who would become a community leader, was due to fly 1,000 kilometres to Moose Factory, Ont., to give birth. “I really didn’t want to go,” she says, 28 years later. A doctor agreed to help her in the community. Her husband was there and her children met the newborn hours after he arrived. It was the beginning of bringing birth back to the village.

Puvirnituq, population about 1,400, is a community with an independent streak. Its residents refused to sign the James Bay and Northern Quebec agreement in 1975.

Dissatisfaction with the birth policy was brewing in the community when the province offered to build a hospital there in the mid-1980s. Tulugak was part of a group that travelled around Nunavik asking people how they could improve maternity services. She also became head of the hospital board in Puvirnituq after the previous chair objected to plans for a midwifery clinic and resigned. Out of those meetings grew a pilot project that would become the Inuulitsivik maternities, serving women in seven communities.

The community wanted midwives to work with nurses and doctors as primary caregivers for all low-risk pregnancies. A committee would assess who needed to be sent south.

They battled conventional wisdom and warnings that it was too risky.

Over the years, the program won respect and recognition.

Midwives were initially brought in from elsewhere, working with doctors and nurses. The midwives also acted as mentors to Inuit student midwives. The Inuulitsivik Midwifery Education Program adapts the southern curriculum to “northern realities,” in the words of Vicki Van Wagner, of Ryerson.

Twelve years after Puvirnituq’s birth centre became a reality, a second one was set up in the village of Inukjuak, south along the Hudson Bay coast. Salluit’s centre opened in 2004.

The three maternities serve seven villages with a population of about 5,500. Residents of smaller communities fly in.

About 3,000 babies have been born at the maternities since 1986. Since the program began, 86 per cent of mothers from the coast gave birth in Nunavik, the majority in their own communities. The remaining 14 per cent were sent south because their pregnancies were deemed high risk.

In Nunavik, midwives do more than just deliver. They act as community health workers, educating the community about the dangers of smoking and drinking while pregnant, the importance of nutrition and how to prevent sexually transmitted diseases. They also serve as role models. Because pregnant women visit them monthly and then weekly at the end of their pregnancies, midwives have influence.

On Sept. 9, International Fetal Alcohol Syndrome Day, midwives across Nunavik spread the message about mixing alcohol with pregnancy. In Puvirnituq, the mother of a child with FASD called a radio program to warn others not to make the same mistakes she had. Village bells rang at 9:09 a.m. (the nines represent the months of pregnancy) to underline that message.

Farther north in Salluit, meanwhile, children laughed and played games at a community centre event organized by local midwives to mark the day.

Unlike their parents, most of these children had been born close to home, just up the hill in the Maternity.

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